The transition from public to private

(31 March 2018)

I find myself marveling at the difference between the public sector, and private practice. I never imagined myself to have experienced some of the things I have so early on in my career.

Working in a government hospital in South Africa for a year has exposed me to a whole different world. Being fresh out of varsity (well, sort-of), you walk in to your first ever job, and are expected to take the lives of sickly people into your hands and make a confident call regarding their treatment. That is a scary thought. Let me explain…

As a Speech Therapist, part of our scope of practice is working with people who experience swallowing difficulties. That is, a neurological, physiological or muscular problem has occurred, causing a patient to either aspirate (food enters the airway) on their food, or be at high risk for this to happen. In a nutshell, imagine drinking a glass of water, and having some of it go to your lungs. Now this doesn’t only happen on water, but on everything you eat. It will most likely result in the development of pneumonia, or worst case scenario cause a patient to drown on their food.

So nonetheless, I walk into community service, head held high, feeling very important, and trying my absolute best to hide my very intense nerves. Needless to say it took me no longer than two weeks to be humbled and very quickly realize that those nerves were there for a reason. Doctors ask you questions that you (a) don’t understand 80% of, and (b) are expected to be able to answer with accuracy. So you waffle, and talk the biggest load of hogwash, throwing a couple of academic terms in to sound like you know what you are saying. Not even to mention you now have to work with patients who have all kinds of funny illnesses, diseases, psychological imbalances and some very traumatic injuries. To mention a few, I worked with people who were brutally attacked to the verge of death, kidney failure patients, epilepsy patients, babies who were born unable to suck, children with neurological difficulties, autism kiddies, cerebral palsy kids, psychological traumas, stroke patients, and more. Often you will come across a patient by accident, who has been misdiagnosed by the new intern doctor who “forgot” to refer to you. This is government. You don’t wear your nice shoes and good clothes to work, because at the end of the day you walk out feeling a sense of urgency to find a shower, and wonder what will come across your path tomorrow.

I started in private practice in January of this year (2018), and am astounded by the complete change in atmosphere, the respect now shown to you, and the prevalence of dysphagia cases! Suddenly, doctors (well, about 60% of doctors) know what you do, and will refer patients to you. Your requests for feeding tubes are seen to as soon as possible, if not on the same day, and low and behold, your patients understand you!! Coming from a setting in which most of your population is third, fourth or fifth language English speakers, suddenly 90% of your clients are first language speakers, and can communicate with you on a level far beyond any experience you may have gotten. Eeeek!! Now suddenly I have to start sounding like I know what I am talking about, and actually making sense too. I have now been working in private for a total of three months, and already I have learned more than what I learned in community service and university combined. Okay, perhaps varsity laid out the groundwork for me, but the extent to which application of knowledge is actually used is astronomical. You dig so deep, and come up with these seemingly far-fetched conclusions that really actually make sense, and earn a high level of respect from the doctors and the allied community. Critical in-patients need to be seen daily, and bi-weekly or weekly for out-patients, where in the past many were only seen once a month.

You often come across people who say they hate their jobs, and that work will always be work. I am one of the lucky few who can honestly say that I love my job. Yes sure, I very often feel like I am drowning, turn into a stress-ball, and wish that I could finish work earlier, or have a day off here and there, but on the whole, my job never ceases to amaze me. Not a day goes by that something interesting doesn’t happen; sometimes patients will say things that have you balling with laughter, you will make someone’s day by telling them their PEG tube can be removed, you will get a smile from that very sick ICU patient who can hardly function, or you will be called a “rude pig” by your delusional patient for not giving them a sip of water.

Although the nature of many of the cases we come across in public and private is the same, there is a certain level of care demanded from you in private that you won’t find in government. You are now able to communicate with patients on a high level, you are taken seriously by your colleagues and other professionals, and your job suddenly becomes important. Hospitals now become your home. Medicine fascinates you, and you are no longer that afraid of needles (hmmmm, yes okay that is debatable, but you do become accustomed to the necessity thereof, and won’t fight against it anymore). The transition from public to private was daunting, and took some time, but man oh man has it been a fun journey.

Later…

Xxx

There is no changing an already made-up mind

9 November 2017

So I have a patient, he is a very sweet little boy (Ben) with a rather sad background. He is 4 years old, and lives with his grandparents and brother. His mom is still in the picture, and spends time with him once every two weeks, or something crazy like that. They came for therapy the other day, and Ben’s granny was telling me about recent developments in this child’s life.

As a young boy, Ben grew up almost in the shadow of his older brother. His father had developed a bond with his brother, that was not carried over to Ben. He would praise his brother, buy him stuff, they would do things together, and none of this would ever happen with Ben. Ben would be pushed around, his father would physically hurt him if he did the smallest thing wrong, and would tell him that he is worthless and should never have been born. His mother, it seems, was a drug addict, and also did not pay much attention to the children and how they were being treated. Long story short, granny saw what was happening, and had a social worker take the kids away from their parents, to now live with their grandparents. Since then, their father has disappeared, and is nowhere to be found, and their mother is now rehabilitating herself, and is doing everything in her power to be a good mother and be a part of their lives.

When Ben first arrived by me, he was extremely shy, did not want to participate, and appeared almost afraid of disobeying his grandmother. I would ask him questions, and his granny would repeat the questions and tell him, rather sternly, to answer. But, we slowly made it through the assessment, and Ben started trusting me and opening up to me more and more. He makes eye contact, does not avoid physical touch, and follows instructions as any 4 year old child would. He enjoys colouring in, and is eager to learn and absorb more information. Ben is a clever little boy, and does well with most activities presented to him.

In my professional opinion, I believe that Ben is neurologically and physiologically fine. I do, however, believe that his personal history with his parents has left some psychological and emotional damage, and that this is what is causing his difficulties in expressing himself, and to a certain extent, hampers his learning. I am not sure whether he has ever been seen by a psychologist, but I do believe that his difficulties are stemming from his emotional and psychological trauma as a young boy.

Ben’s granny one day asked me whether I could book him an appointment with the paediatric neurologist, because she believes that he is Autistic. She has done a lot of reading up on Autism, and the more she reads, the more she is able to identify behaviours in Ben that are indicative of Autism. At the time, I did not agree with her deductions per se, because from what I had seen, there is not much that would indicate Autism. Sure, Ben fixates on the number 13 when we are doing numbers, but other than that there is not much more. He tends to isolate himself from other friends, assumingly for fear of rejection, his emotional past, and he demonstrates difficulty with production of various speech sounds (which has been identified as the result of recurrent ear infection).

Once Ben had been to the paediatric neurologist, his granny came back to me and told me that they say they do not have a diagnosis for him. The wording they used in their letter to me was “Dear Lauren, thank you for your referral of Ben to paeds neuro. Ben is developing well, and shows great improvement from Speech Therapy. Please continue your exceptional work with him”. In other words, no diagnosis. His granny was rather distraught by this result, because she firmly believes that he has got Autism. She then starts telling me about a series she is watching, called “Atypical”, about a boy who has Autism, who is in high school and is trying to find love. She says to me that all the behaviours he demonstrates are what she sees in Ben, and she is sure he has Autism.

I am currently busy watching the series, and no doubt that the behaviours that the actor demonstrates are those of an individual with Autism, but I can honestly say that I do not agree with his grandmother. I do not believe that Ben has Autism, I do believe that his background has the biggest role to play in his current functional abilities. I also find it rather sad that his grandmother, who spends most of her time with him, is looking for a label to pin to her boy, so that she can blame it on that. I will never tell her she is wrong, because as a professional I can only tell patients what my recommendation would be, and perhaps refer them to a psychologist, but it breaks my heart that the only way around this for her is to label this poor boy something that he is not.

Until later…

Xoxo

The feeling of making a difference...

(29 June 2017)

The feeling of making a difference…

Two years later and the inspiration hits me once more… I am currently a community service Speech-Language Pathologist at a public hospital in Pretoria, South Africa. Since I last wrote, I completed my honors degree, obtained my Masters degree, and have now been working for six months.

So I get to work on Monday feeling tired and demotivated after a busy weekend. I’m going through the motions for the day, running around like a mad thing with all the patients, because my colleague is on leave. After lunch I finally manage to go to the wards. So because the hospital that I work in is small, our wards are combined medical and psychiatric patients. Up I go to ward five (the male ward), and I have got two referrals, one of which is a TBI (traumatic brain injury). So I go to the patient, glance at him (he doesn’t look good) and start off by reading the file.

So Mr X’s name in the file is “Delta Unknown”, he was admitted to the hospital over the weekend – down-referred form a tertiary hospital’s neuro ward because they needed the bed. Mr X was assaulted and admitted to hospital on the 3^rd of March 2017, where he has been diagnosed with severe TBI and dehydration. They still do not know his name, and state that he cannot communicate. Every now and then Mr X would make this moaning noise, almost a cry, for a reason not apparent to me.

So I approach the patient with hopes not being too high, and a slight sinking feeling in my stomach because I expect the prognosis to be poor… The patient is lying on his back, in a position that is similar to a foetal position in an infant, in a nappy, and my goodness is he skinny. His thighs the size of my forearm. I approach him while putting my gloves on and try and wake him up. The patient is looking at the roof with an expression of non-recognition, suggesting visual difficulties. As I start talking, he makes that moaning noise again, and my hopes drop just a little bit more… This patient isn’t all that aware of what his circumstances are, or what has happened. Before I finish, I quickly had to do a basic swallow assessment on this patient. So I bring the glass of water closer to his mouth, and he purses his lips as though he knows that is going to happen (interesting). So I give him a sip of water, and feel a safe, strong swallow, when through clenched teeth and in a whisper, says to me “more please”. Just to confirm that I heard him correctly, I ask him “sir would you like some more water”, and he answers “yes please”. Through small sips of water, and very basic questions, I managed to find out Mr X’s name, his age, and where he is from before he became upset and distraught again.

I told the nurses how I managed to get this information out of him, so when I arrived at work the next day, during meal times one nurse had managed to obtain a contact number and get hold of his family. What an amazing development! And this because I managed to figure out that this patient is somewhat aware of his surroundings, and is able to communicate. I walked into Mr X’s hospital room the following day, to find his family crowded around him crying. His father, an elderly man, looked up at me and said “thank you”. I have never before been speechless in front of one of my patients, but that day I was unable to say a word, and had tears streaming down my face as I watched them reunite with their son (who they believed had been dead for the last 4 months).

Where we stand today (November 2017), almost 5 months later, I have just discharged Mr X from Speech Therapy. He has gained weight, he is feeding well, and has developed into a witty young man with a good sense of humour. Mr X now loves with his three lovely sisters, and although he is still wheelchair bound and completely reliant on others to get him from one place to the next, intends on studying mechanical engineering in 2018.

Being a Speech Therapist, especially in the public sector, it becomes somewhat of a necessity to develop a certain ‘hardness’ towards your patients. We see some very upsetting cases, people who have been brutally beaten, or who have some serious neurological deficits, and yet we still need to hold our heads up high and put a smile on our faces every day. We need to learn how to be stern to those patients who are refusing therapy, and we need to make the call on how a patient will be able to feed whether they are fully functional or not. There is a lot that falls on us as therapists, and a lot more than what the medical community believes. We are the invisible healers…

Watch this space for more stories and insight into the life of a new Speech Therapist…

Xoxo